The Citium

The Order of Citium is a composite of several secret societies, and is partially based on fact:

- Citium is the Latin name for the ancient Greek city of Kition, a city-kingdom on the southern coast of Cyprus (in present-day Larnaca).

- Zeno of Citium was a philosopher from the city of Kition. He was the founder of the Stoic school of philosophy, which he taught in Athens from about 300 BC. Zeno divided philosophy into three parts: Logic (a very wide subject including rhetoric, grammar, and the theories of perception and thought); Physics (not just science, but the divine nature of the universe as well); and Ethics, the end goal of which was to achieve happiness through the right way of living according to Nature.

CDC & EIS

Mostly fact:

The CDC is located just outside the Atlanta city limits, to the northeast, in the affluent Druid Hills community in unincorporated DeKalb County. The CDC’s precursor organization was founded in Atlanta for one simple reason: to combat malaria. At the time, in July of 1946, the disease was America’s greatest public health concern, especially in the hot, humid southeast. Being centrally positioned in America’s malaria hotbed had been a significant advantage.

The Emergency Operations Center (EOC) is the CDC’s command center for outbreak responses.

The EIS program is a two-year fellowship established at the CDC in 1951. It began as a Cold War initiative focused on bioterror. Today it is one of the most prestigious and sought-after fellowships in applied epidemiology, known for producing the world’s best disease detectives. Candidates applying to the program need to be a physician with at least a year of clinical experience, a veterinarian, a PhD-level scientist with a background in public health, or a health care professional with at least an MPH degree. There ar currently about 160 EIS officers, seventy percent of whom were women.

During their fellowship, EIS officers often work in the field, on the front lines of outbreaks. During the 2014 Ebola outbreak, every one of the 158 EIS officers deployed. They served in seventeen countries, eight states, Washington, DC, and the CDC’s Emergency Operations Center. During that time, they contributed 6,903 days of service—almost nineteen years combined.

US Public Health Service Commissioned Corps

Mostly fact:

The Commissioned Corps is an elite team of highly skilled health professionals and one of the United States’ seven uniformed services (the other six being the Army, Navy, Air Force, Marines, Coast Guard, and National Oceanic and Atmospheric Administration Commissioned Corps). Over six thousand men and women serve in the Public Health Service Commissioned Corps, and they wear uniforms similar to the US Navy’s: service dress blues, summer whites, and service khakis. Commissioned Corps officers hold the same ranks as the Navy and Coast Guard: ensign to admiral.

Commissioned Corps officers serve at the EPA, FDA, DoD, NIH, USDA, Coast Guard, CDC, and many other organizations. They are often the first responders during national disasters, and have deployed in response to hurricanes, earthquakes, and outbreaks. In 2001, over one thousand PHS officers deployed to New York City after the 9/11 attacks. In 2005, in the aftermath of three hurricanes—Katrina, Rita, and Wilma—more than two thousand PHS officers deployed to set up field hospitals and assist victims.

Over eight hundred Commissioned Corps officers work full-time at the CDC. Visitors often mistake them for Navy officers because of the similar uniforms and rank.

Security in Kenya

Mostly fact:

In August, 1998 truck bombs exploded outside the US embassies in Nairobi, Kenya, and Dar es Salaam, Tanzania. In Nairobi, 213 people died. Four thousand were injured. The attack was linked to al-Qaeda. In fact, it’s what caused the FBI to put bin Laden on the ten-most-wanted list for the first time. Less than two weeks later, the Clinton administration launched cruise missiles at Sudan and Afghanistan in Operation Infinite Reach. The hit on bin Laden failed. In response, the Taliban renewed their commitment to harbor him, and the rest is history.

The US State Department decided not to rebuild the embassy that was bombed in Nairobi. They built a new embassy directly across the street from the UN for security purposes.

In the years since the Nairobi bombing, the security situation in Kenya has gotten worse. Crime is high everywhere in the country. It’s particularly bad in the larger cities: Nairobi, Mombasa, Kisumu, and the coastal resorts. In Nairobi alone there are ten carjackings every day. In May 2014, the US, UK, France, and Australia began issuing travel warnings to their citizens in Kenya. The US went further, reducing our staff at the Nairobi embassy. The UK closed their consulate in Mombasa. The effects of the travel advisories were devastating to the Kenyan tourism industry. European travel to the country ground to a halt.

US embassy personnel must get express permission when traveling outside Nairobi, and in some neighborhoods in the city.

In May of 2015, Doctors Without Borders evacuated personnel from the Dadaab refugee camp because of security concerns. In total, they evacuated forty-two staff members to Nairobi and closed two of their four health posts.

In July 2014, the Peace Corps suspended all activities in Kenya and evacuated all of its personnel because of the security situation.

Pandemics in History

All factual:

In the third century, the Antonine Plague wiped out a third of Europe’s population. And just when population levels were recovering, the Plague of Justinian in the sixth century killed almost half of all Europeans; up to fifty million people died from what we believe was bubonic plague.

In the 1340s, the Plague once again remade Europe, forever changing the course of world history. At that time, we believe the world population was around 450 million. The Black Death killed at least 75 million. Some estimates go as high as 200 million. Imagine, in the span of four years between twenty and fifty percent of the world population dying.

Europe, because of its large cities, population density, and advanced trade routes, has repeatedly been a hotbed for pandemics. But it is not alone.

Consider the New World when Europeans arrived. We’ve heard so much about the plight of native peoples in the present-day United States, but consider the populations of New Spain, present-day Mexico. In 1520, smallpox killed nearly eight million. Twenty-five years later, a mysterious viral hemorrhagic fever killed fifteen million—roughly eighty percent of their population at the time. Imagine that: a mysterious illness killing eight out of every ten people. In America, that would be over 240 million people. It’s unthinkable, but it happened, right here in North America, less than five hundred years ago. We still haven’t identified the pathogen that decimated Mexico in the sixteenth century, but we do know it returned twenty years later, in 1576, following two years of drought. It killed another two million from the already decimated population. To this day, we still have very few clues about what caused that pandemic. Most importantly, we don’t know if or when it will return.

In 1918, the Spanish Flu, or, as it’s more recently known, the 1918 Flu Epidemic, infected nearly one in three people around the world. It killed one in five people who fell ill with the disease. As many as fifty million died. We think twenty-five million died in the first six months of the outbreak.

Today, we are more connected than ever before. Our population is four times larger than it was at the time of the last major global pandemic in 1918. We’re more urbanized. We’re disturbing more animal habitats. Most concerning, we are disturbing habitats where reservoir hosts for extremely deadly diseases reside. Fruit bats, rats, squirrels, fowl, and other hosts for zoonotic diseases are coming into contact with humans with greater frequency.

Mandera, Kenya

Mostly fact:

Mandera is the poorest of Kenya’s 47 counties. Education ranks at the bottom; there are a hundred students for every teacher. Health care facilities are the worst in the country. Mandera’s residents are largely subsistence farmers and ranchers. The economic situation is dire. Per capita income is 267 US dollars—less than 75 cents per day. The dusty, dirt road town is situated at the crossroads of three nations: Kenya, Somalia, and Ethiopia.

The world’s deadliest diseases are endemic to the region, including Rift Valley Fever, Ebola, and Marburg. But they were far from the most dangerous elements in the area. Al-Shabaab, an Islamic terror group and affiliate of al-Qaeda, attacks the villages and government facilities frequently.

In 2013, the Kenyan government begun a process of devolution, handing much of the governing power in Mandera down to the county government. With the help of non-governmental organizations like the Red Cross and the UN, as well as support from the Kenyan government, the county has started turning its situation around. They’ve embarked on several large public works projects, including upgrading the airport and building a new government complex, a stadium, and an international livestock market.

Al-Shabaab

Mostly fact:

Al-Shabaab is an Islamic terror group based in Somalia, with cells and operatives throughout Kenya. They want to turn Somalia into a fundamentalist Islamic state. They’re essentially ISIS in East Africa. The African Union has deployed twenty-two thousand troops to Somalia to try to contain them.

In April 2015 al-Shabaab attacked students at Garissa University. They singled out Christians and shot them. In total, they killed 147 people in the attack.

In December 2015, al-Shabaab militants stopped a bus outside Mandera and ordered all the Muslim passengers to get off. They refused and instead crowded around the Christian passengers. Al-Shabaab dragged everyone from the bus—both Muslim and Christian—lined them up, and shot them. Thirty-seven people died that day.

In March of 2016, the US received intel that al-Shabaab was planning a large-scale attack on US and African Union forces in the region. The Air Force launched a strike in which manned aircraft and unmanned MQ-9 reaper drones hit an al-Shabaab training camp in northern Somalia. About 150 of al-Shabaab fighters, including their number two were killed.

GPHIN

All factual.

The World Health Organization and Health Canada operate an early warning system for pandemics. The system is called the Global Public Health Information Network, or GPHIN for short, and it has saved countless millions of lives.

In 2003, GPHIN identified SARS in Hong Kong long before local health agencies knew what was going on. SARS remained a largely regional epidemic instead of a global pandemic thanks to GPHIN and the prescient actions of several health workers, including a doctor who ordered the slaughter of 1.5 million chickens and birds who were likely infected with the virus.

In 2012, GPHIN again detected warning signs of an outbreak—this time of a respiratory illness in Jordan. The system was again correct, predicting the Middle East Respiratory Syndrome Coronavirus—MERS-CoV—before it went global.

In a sense, GPHIN is to global pandemics what the seismometer and Richter scale are to earthquakes. Where the seismometer reads ground movement and provides alerts before an earthquake, GPHIN gathers health data and provides alerts before an outbreak. Every day, GPHIN monitors feeds from local, state, regional, and national health departments. It also crawls social networks and blogs, compiling data and looking for signs of new threats.

Dadaab Refugee Camps

Mostly fact.

The camps in Dadaab are sprawling settlements. There are several camps for refugees and a smaller camp for aid agencies.It is the site of a UNHCR base hosting 256,868 refugees in five camps (Dagahaley, Hagadera, Ifo, Ifo II and Kambioos) as of January 2017, making it the largest such complex in the world.

The Dadaab refugee camp complex is so vast that it has been compared to a city. Like many cities, Dadaab features public service buildings such as schools and hospitals. The Ifo II camp includes religious spaces, a disability center, police stations, graveyards, a bus station, and more. The camp is designed in a grid-like pattern, with the market on one side and a green belt at the center of the many lines of tents. Despite these many amenities, however, the camps are crowded and have few signposts, making them confusing and difficult to navigate for new arrivals.

Refugees in Dadaab typically live in tents, which are made of plastic sheeting and distributed by the UNHCR. Although many residents have voluntarily repatriated, the camps are still overcrowded and exceed their intended capacity. In addition to tents, some residents have built makeshift homes for shelter and to escape the heat of the sun. On average, four people live together in each household.

Aralsk-7

Mostly fact, though the site has been abandoned since 1991.

In 1948, the Soviet Union built a top-secret bioweapons lab on Vozrozhdeniya Island. The Russian name translates to roughly ‘Rebirth Island’ or ‘Renaissance Island.’

The USSR expanded the facility in 1954 and renamed Aralsk-7. The Soviets’ Microbiological Warfare Group operated there, testing some of the world’s most lethal pathogens. In 1971, they accidentally released a weaponized form of smallpox. Ten people were infected; three died. People who worked at Aralsk-7 have admitted to working on anthrax spores and strains of bubonic plague—both of which were weaponized.

The site was officially shut down in 1991. All the military and civilian personnel were evacuated. The town on the island, Kantubek, which had housed fifteen hundred people who worked at the facility, became a ghost town.

The Aral Sea has been shrinking since the sixties when the Soviets diverted the rivers feeding it for irrigation projects. The Aral Sea is now about ten percent of its original size. In fact, it’s just four large lakes at this point. In 2001, the water had drained enough for Vozrozhdeniya Island to reconnect with the mainland, making it a peninsula instead of an island.

Ebola

All factual.

It takes a human anywhere from two to twenty days to develop Ebola symptoms. On average, infected individuals develop symptoms eight to ten days after contact with the virus.

Ebola and other filoviruses are all zoonotic—they jump from animals to humans and back. Zoonotic infections are a huge issue in central Africa. In fact, seventy-five percent of all the emerging infectious diseases there are zoonotic in nature.

The natural reservoir host for Ebola remains unknown, but we’re almost certain that African fruit bats harbor the virus without symptoms. When it jumps from bats to humans, it wreaks havoc.

There is a field test for Ebola: the ReEBOV Antigen Rapid Test Kit. ReEBOV gives a result in about fifteen minutes. Accuracy is 92% for those infected and about 85% for those negative.

There is no FDA-approved treatment for Ebola or Marburg. There is no vaccine. If a patient breaks with the disease, they are given fluids, electrolytes, and treatment for any secondary infections.

The average Ebola case fatality rate is fifty percent.

There are five known strains of Ebola: Zaire, Ivory Coast, Sudan, Bundibugyo, and Reston. Reston ebolavirus is the only strain that’s airborne. It’s named Reston because it was discovered in Reston, Virginia, only miles from the White House. It is quite possibly the greatest piece of luck in human history that the Reston strain only causes disease in non-human primates. In fact, in the course of the Reston outbreak—which occurred at a primate facility—although several researchers were infected, all remained asymptomatic. If Ebola Reston had been deadly for humans, there would be a whole lot fewer of us around today. The other four strains of Ebola are among the most deadly pathogens on the planet. Zaire ebolavirus is the worst, killing up to ninety percent of those it infects.

ZMAPP

Fact.

ZMapp is the only therapy that has proven effective in treating Ebola. It did very well in primate trials. During the West African Ebola outbreak in 2014, the CDC treated seven Americans with ZMapp and an RNA interference drug called TKM-Ebola. Two of those patients died, but five survivors out of seven is still better than the average survival rate. ZMAPP is not FDA-approved and has had mixed results in humans.

M13/GP3

Mostly factual:

In 2004, an Israeli researcher named Beka Solomon was conducting Alzheimer’s trials when she stumbled onto a new therapy that reduced the brain plaques associated with Alzheimer’s by an astounding eighty percent. That made it far more effective than any treatment on the market.

But Solomon had actually begun her trials with a focus on a completely different therapy. She had genetically engineered mice to develop Alzheimer’s and was treating the mice with a human-derived antibody, which she administered via their nasal passages. The problem was, her therapy didn’t effectively cross the blood-brain barrier and reach the plaques in the parts of the brain affected by Alzheimer’s. In what might go down as one of the greatest twists of scientific luck, Solomon decided to attach her antibody to a virus called M13 to transport it across the blood-brain barrier.

M13 is a special type of virus called a bacteriophage—a virus that infected only bacteria. And M13 infects only one type of bacteria: Escherichia coli, or E. coli. To Solomon’s surprise, the antibody, when attached to M13, showed great success in her trials. But what was truly surprising was that the group of mice treated with the M13 virus alone—without Solomon’s antibody therapy—also showed incredible improvement. It seemed that the positive outcomes from the trials were due entirely to M13, not to Solomon’s actual antibody therapy. After a year of treatment, the mice that received M13 had, on average, less than a fourth of the plaques of those in the control group. Subsequent experiments showed that M13 could also dissolve other amyloid aggregates—the tau tangles found in Alzheimer’s and the amyloid plaques associated with other diseases, including alpha-synuclein (Parkinson’s), huntingtin (Huntington’s disease), and superoxide dismutase (amyotrophic lateral sclerosis). The M13 phage even worked against the amyloids in prion diseases, a class that included Creutzfeldt-Jakob disease. The discovery was startling and represented a potentially huge breakthrough in the fight against neurodegenerative diseases.

Thus began the long process of trying to figure out how M13 did its miraculous work. After years of research, scientists discovered it was actually a set of proteins—called GP3—on the tip of the M13 virus that was the key to its incredible ability. The GP3 proteins essentially enable M13 to attach to E. coli and unzip the bacteria, allowing M13 to inject its own DNA inside for replication. And by a stroke of sheer luck, the GP3 proteins also unlocks clumps of misfolded proteins found in Alzheimer’s, Parkinson’s, Huntington’s, and other diseases.

Memory Storage and Alteration

Fact and Fiction.

Fact:A few years ago, researchers at MIT discovered a way to actually isolate the location, in the brain, of specific memories. It was a breakthrough—the revelation that individual memories were stored biochemically in specific groups of neurons in the hippocampus.

RSV Beagle

Fiction.

Rubicon

Fiction.

Operation Pied Piper

Fact.

Operation Pied Piper was the UK’s coordinated effort to remove as many citizens from harm’s way as possible when World War II began. Over 3.5 million people were displaced. In the first three days of September 1939, over 1.5 million people were moved, including 800,000+ school age children, over 500,000 mothers and young children, 13,000 pregnant mothers, and 70,000 disabled people. Another 100,000 teachers and support personnel were moved.

The evactuations are mentioned in William Golding’s The Lord of the Flies and C. S. Lewis’s The Lion, the Witch and the Wardrobe.

Ash Wednesday Bushfire

Fact.

The Ash Wednesday bushfires, known in South Australia as Ash Wednesday II, were a series of bushfires that occurred in south-eastern Australia on 16 Feb 1983, which was Ash Wednesday in the Christian calendar.

Seventy-five people died and thousands were injured. Property damage was extensive: nearly 4,000 buildings destroyed and over 2,500 families lost their homes. Livestock losses were also very high. Over 340,000 sheep, 18,000 cattle and numerous native animals died during the fire or were later put down. Insurance claims exceeded $1.3 billion in inflation adjusted losses.

The emergency saw the largest number of volunteers called to duty from across Australia at the same time—an estimated 130,000 firefighters, defence force personnel, relief workers and support crews. Charlotte Christensen is a fictional character meant to represent the men and women who served in the aftermath of the fires.

Operation Bioshield

Mostly fiction, though the The Project Bioshield Act passed in 2004 by the US congress did call for $5 billion for purchasing vaccines that would be used in the event of a bioterrorist attack.

The act authorized a ten-year program to acquire medical countermeasures to biological, chemical, radiological, and nuclear agents for civilian use. A key element of the Act was to allow stockpiling and distribution of vaccines which had not been tested for safety or efficacy in humans, due to ethical concerns.

Since the 2001 terrorist attacks, the United States government has allocated nearly $50 billion to address the threat of biological weapons. Efforts toward cooperative international action are part of the project.

The Project Bioshield Act established a dedicated strategic planning function that more efficiently integrates biodefense requirements and streamlines the interagency governance process. Under the reorganized structure, on behalf of the secretary of HHS, the Assistant Secretary for Preparedness and Response (ASPR) leads the federal public health and medical response to acts of terrorism or nature and other public health and medical emergencies.

The Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 reauthorized BioShield Project and the Special Reserve Fund (SRF), originally established in 2004.

The Trinity Test

Fact.

The details of the first atomic bomb test described in the book are accurate:

In the hours before the test, the mood across the Alamogordo Bombing and Gunnery Range was tense. Inside the control station, the Manhattan project director, Robert Openheimer, was bordering on a breakdown. Several times, the general overseeing the effort had to guide the man outside, where they walked in the darkness, through the rain, talking, the general assuring him all would go as planned.Shortly before five thirty a.m., the countdown began.

The team had nicknamed the device the Gadget. That morning, the Gadget sat atop a one-hundred-foot-tall steel tower. Desert stretched in every direction. The control station where the scientists waited was nearly six miles away. Even at that distance, they donned welder’s goggles and focused through the tinted glass. They saw only darkness in the seconds before the countdown reached zero.

The flash of white light came first. It lasted for a few seconds, then a wave of heat passed through them, soaking their faces and hands. When the wall of light faded, one could make out a column of fire rising from the site, expanding quickly.

The cloud broke through a temperature inversion at seventeen thousand feet—which most scientists had thought impossible. For minutes after the explosion, the cloud rose into the sky, reaching the substratosphere at over thirty-five thousand feet.

Forty seconds after the detonation, the shock wave reached the scientists in the control station. The sound of the blast followed shortly after. It had the quality of distant thunder, reverberating off the nearby hills for several seconds, giving the impression of a rolling thunderstorm. The sound was heard up to a hundred miles away; the light from the explosion was seen from almost twice as far.

The blast instantly vaporized the steel tower that held the bomb, leaving a crater nearly half a mile wide in its place. An iron pipe set in concrete, four inches in diameter, sixteen feet tall, and fifteen hundred feet away from the detonation, was also vaporized.